This subchapter applies only to certain health benefit plans with referral requirements for specialty care, and to listed plan types and risk-pool coverage described in the section.
Sec. 1451.252. APPLICABILITY OF SUBCHAPTER. This subchapter applies only to a health benefit plan that requires an enrollee to obtain certain specialty health care services through a referral made by a primary care physician or other gatekeeper and that: (1) provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including: (A) an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage that is offered by: (i) an insurance company; (ii) a group hospital service corporation operating under Chapter 842; (iii) a fraternal benefit society operating under Chapter 885; (iv) a stipulated premium company operating under Chapter 884; or (v) a health maintenance organization operating under Chapter 843; and (B) to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health benefit plan that is offered by: (i) a multiple employer welfare arrangement as defined by Section 3 of that Act; or (ii) another analogous benefit arrangement; (2) is offered by: (A) an approved nonprofit health corporation that holds a certificate of authority under Chapter 844; or (B) an entity that is not authorized under this code or another insurance law of this state that contracts directly for health care services on a risk-sharing basis, including a capitation basis; or (3) provides health and accident coverage through a risk pool created under Chapter 172, Local Government Code, notwithstanding Section 172.014, Local Government Code, or any other law. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.